Let's Get Fewer People to Die (from Northeastern Law Magazine)

Elisabeth Ryan, the head of Public Health Law Watch, wrote an essay about gun violence for the latest issue of the Northeastern Law Magazine.

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by Elisabeth Ryan

Guns were never a part of my life.  In the Massachusetts suburb where I grew up, my family did not go target shooting for sport and did not keep guns in the home for protection. The very idea of hunting was repugnant in our animal-loving household. In law school, my constitutional law classes never even mentioned the Second Amendment. My life was, in all tangible aspects, unaffected by guns.  But when I worked as a public defender, I represented people who commonly faced rampant violence in their lives and neighborhoods. For them, guns were often just part of reality. When I worked as counsel in the Massachusetts Executive Office of Public Safety and Security, overseeing state gun laws, regulations and policies brought me into contact with a population of individuals for whom guns were a central part of their lives, both tangibly and symbolically. 

I became aware that in the political world otherwise obsessed with firearms, recognition of gun violence as a public health issue was almost entirely absent.  So after years of practicing law, I went back to school and earned my MPH to study just that.

My mission now sounds deceptively simple: change the narrative around firearms from a bitterly partisan “us versus them” fight into a shared goal of getting fewer people to die.  To get closer to that goal, I think a few points are crucial to understand. 

First, the Second Amendment is not unlimited, contrary to what the pro-gun lobby espouses.  No right protected by the Constitution is unlimited.  And until the Supreme Court decided D.C. v. Heller in 2008, the law wasn’t even clear that the Second Amendment protected an individual right to possess a gun, as opposed to a collective right for militias.  In no way – now or ever –does the Second Amendment preclude stronger gun laws aimed at saving lives.

Second, the federal government essentially prohibits the Centers for Disease Control and Prevention (CDC) from conducting research on gun violence and that needs to change. In the 1990s, Congress deemed that a recent federally funded study that showed an association between guns in the home and increased homicide rates was anti-gun advocacy.  It subsequently stripped the CDC budget of the money previously allocated for firearms violence research and inserted a clause saying that no money “may be used to advocate or promote gun control." That clause has remained in every single federal budget since 1996.  The federal government needs to affirmatively fund research into a crisis that kills 30,000 people per year.  Refusing to do so devalues tens of thousands of lives.

Finally, some people will always value owning guns more than they value human lives and no amount of data or evidence will convince them otherwise.  But that doesn’t hold true for most gun owners.  Saving lives by preventing gun violence does not mean having to eschew gun ownership.  It can mean doing research, treating gun violence as a public health issue, increasing technological safety advances or tightening regulations on gun purchasing and storage.  It can start with laws, but also with friends, with gun dealers and with health care workers.  If we can all make the goal "let's get fewer people to die," I have no doubt that we can accomplish it.

The original essay published in the Winter 2018 issue of Northeastern University School of Law Magazine can be found here.

Involuntary Treatment for Substance Use Disorder: A Misguided Response to the Opioid Crisis [from Harvard Health Blog]

PHLW's Leo Beletsky, Elisabeth Ryan, and Wendy Parmet authored a piece this week on the Harvard Health Blog about why involuntary commitment for substance use disorder should not be touted as a tool in the opioid crisis.

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Recently, Massachusetts Governor Charlie Baker introduced “An Act Relative to Combatting Addiction, Accessing Treatment, Reducing Prescriptions, and Enhancing Prevention” (CARE Act) as part of a larger legislative package to tackle the state’s opioid crisis. The proposal would expand on the state’s existing involuntary commitment law, building on an already deeply-troubled system. Baker’s proposal is part of a misguided national trend to use involuntary commitment or other coercive treatment mechanisms to address the country’s opioid crisis.

The CARE Act and involuntary hold

Right now, Section 35 of Massachusetts General Law chapter 123 authorizes the state to involuntarily commit someone with an alcohol or substance use disorder for up to 90 days. The legal standards and procedures for commitment are broad; a police officer, physician, or family member of an individual whose substance use presents the “likelihood of serious harm” can petition the court.

Upon reviewing a petition, the court can issue a warrant for the arrest of the person with substance use disorder. The individual — who is not charged with a crime — is held pending an examination by a court-appointed clinician. The statute mandates that the determination proceed at a rapid pace, making it difficult to mount a meaningful defense.

The CARE Act proposes to further accelerate this process. The proposal would allow clinical professionals — including physicians, psychiatric nurses, psychologists, and social workers (or police officers when clinicians are not available) — to transport a person to a substance use treatment facility when the patient presents a likelihood of serious harm due to addiction and the patient will not agree to “voluntary treatment.” Upon determination by a physician that the failure to treat the person would create “a likelihood of serious harm,” the treatment facility has 72 hours to get the person to agree to voluntary treatment. If the person refuses, but the facility superintendent determines that discontinuing treatment would again cause “a likelihood of serious harm,” the facility must petition the court for involuntary treatment under the process outlined in Section 35.

For the full article, access it here.

Threats to Medicaid and Community Integration for People with Disabilities

By Mary Crossley

As we enter the second year of the Trump administration, Medicaid remains in the cross hairs of conservatives in Congress and the administration. The repeated efforts in 2017 to reduce the program’s funding and change its structure, however, revealed the breadth and depth of public support the program enjoys. People with disabilities protested, putting their bodies on the line to express their outrage over proposed cuts that would threaten their access to services that permit them to live in the community rather than institutions. Along with others’, their protests helped defeat Republican proposals in 2017, but similar battles likely lie ahead.

In the recently published “Community Integration of People with Disability: Can Olmstead Protect Against Retrenchment?”,  I explain how the Supreme Court’s holding in Olmstead v. L.C. ex rel. Zimring, combined with changes to Medicaid that permit states to devote funding to home- and community-based services (HCBS),  have contributed to meaningful state progress in enabling people with disabilities to live in the community. The article also considers the extent to which Olmstead could act as a check on a potential retrenchment of support for HCBS if states were to face severe reductions in federal funding for Medicaid. Although states proposing to cut their HCBS programs would likely raise the ADA’s “fundamental alteration” defense and assert that Olmstead recognizes the relevance of budgetary constraints to state decision making, I argue that states should not succeed with a fundamental alteration defense if disabled plaintiffs are suing to forestall cuts to existing HCBS programs and maintain the status quo. In short, Olmstead should provide a check against states’ backsliding in their support for integrating people with disabilities, at least in theory. But people with disabilities probably shouldn’t think that their protesting days are over just yet….

Read the article in Laws.

Center for Health Policy and Law Joins Amicus Brief in Correa v. Schoeck

Public Health Law Watch works in collaboration with the Northeastern University School of Law Center for Health Policy and Law.  The Center has signed on to an amicus brief, in support of the appellant-plaintiff, in the Massachusetts Supreme Judicial Court case of Correa v. Schoeck and Walgreens.  

The amicus brief is available here: Correa v. Schoeck, amicus brief

The issue in this case is "whether a pharmacy owes a duty of care to its customer to notify her physician that her insurer will not pay for her prescription medication without prior authorization."

Yarushka Correa was 19-year-old young woman who had recently been diagnosed with epilepsy after suffering a grand mal seizure.  Doctors placed her on Topamax, which effectively controlled her seizures.  However, her insurance company required that physicians obtain prior authorization before prescribing Topamax. Obtaining such authorization is a relatively routine paperwork process, yet it was never completed in this case. As a result, Walgreens would not dispense the medication and Yarushka was unable to fill her prescription for three months, despite going to Walgreens five times in an attempt to do so. In the normal course of business, and as promised to Yarushka and her mother, pharmacy employees contact the physician to notify of the need for prior authorization. No one at the pharmacy ever did that. Without her medication, Yarushka died after a grand mal seizure.

In the resulting wrongful death case, Walgreens argued that it owed no legal duty to Yarushka to inform her physician of the need for prior authorization before it would dispense her prescription. The Superior Court agreed and granted summary judgment to the pharmacy. Yarushka’s family appealed.

The amicus brief emphasizes that public policy dictates that pharmacy does, in fact, owe such a legal duty to patients.  When a pharmacy fails to inform a prescribing physician that prior authorization is required by an insurance company, it denies patients’ access to necessary medications, which can lead to harm and (as in this case) even death.  "Further, the pharmacy is not just the retail seller of a product, it is an essential part of the health care delivery system, far better equipped than the consumer, who is often vulnerable and in urgent need of medication, to understand and communicate to the physician about insurance payment denials for lack of [prior authorization]."

The case is scheduled for oral argument in the SJC on February 6, 2018.

Immigration and Health Care Under the Trump Administration [from Health Affairs Blog]

PHLW is back with this post by our own Wendy E. Parmet on the Health Affairs Blog.  The piece about the current state of immigration and health care comes out of her recent presentation at the Harvard Law School Petrie-Flom Center Sixth Annual Health Law Year in P/Review in December 2016.

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Immigration and Health Care Under the Trump Administration

by Wendy E. Parmet

Non-citizen immigrants are the canaries in the health care coal mine. Disproportionately poor, non-white, and non-English speaking, and without access to the franchise, they are among the most vulnerable groups in the United States. Consequently, they are often the first to experience the gaps, inefficiencies, and conflicts in our health care system. Meanwhile, anti-immigrant sentiment often spills into health policy debates, as was evident in 2009 when opponents of the bill that became the Affordable Care Act(ACA) focused their opposition on the erroneous claim that it would cover undocumented immigrants. It is therefore not surprising that the first year of the Trump administration, which has focused its domestic agenda on restricting immigration and repealing the ACA, has proven especially perilous for immigrants who need health care.

As a group, immigrants tend to be healthier than the native-born population. They are also far less likely to have insurance. In 2015, for example, 18 percent of lawfully present nonelderly adult immigrants, and 42 percent of undocumented immigrants were uninsured, compared to only 11 percent of United States citizens. Immigrants’ low insurance rate is partly due to the fact that they disproportionately work in sectors of the economy in which employer-sponsored insurance is uncommon. But the law also plays a significant role. Even before the Trump administration took office, immigrants faced an array of legal barriers to obtaining health insurance. Most importantly, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PROWRA) prohibited undocumented immigrants from accessing most federally-funded insurance programs (including Medicaid, Medicare and Children’s Health Insurance Program (CHIP)). PRWORA also barred most authorized immigrants (except refugees) from benefiting from federally-funded programs for five years after obtaining legal status. And although the ACA made it easier for many documented immigrants to gain coverage, it left PROWRA in place. The ACA also limited participation in the exchanges to immigrants who are “lawfully present,” a category that the Obama administration decided did not include the approximately 800,000 young adults who participated in the Deferred Action for Childhood Arrivals (DACA) program. 

The Trump administration’s policies threaten to swell the number of uninsured immigrants, and deter those who have insurance from accessing needed care. For example, several of last year’s Republican proposals to repeal and replace the ACA included specific provisions to bar further classes of immigrants from purchasing insurance on the exchanges, even when they used their own money. Other proposals would have allowed states to deny Medicaid reimbursement for services rendered to eligible non-citizens prior to documentation of their immigration status. In addition, because immigrants tend to have lower incomes than the native-born population and are less likely to have employer-provided health insurance, they would have been disproportionately harmed by efforts to repeal the Medicaid expansion.

Read the entire piece on Health Affairs here: Immigration and Health Care Under the Trump Administration

Will Public Health Litigation Help to Solve the Opioid Crisis?

by Rebecca Haffajee

In this week’s issue of New England Journal of Medicine, Michelle Mello and I write about drug company liability for the opioid crisis. We analyze the history of litigation efforts against opioid manufacturers and distributors to hold these parties responsible, at least in part, for the epidemic. Early litigation brought by individuals harmed by prescription opioids against drug companies was minimally effective: most cases were dismissed early on and few settled. But these personal injury suits faced formidable company defenses -- such as that opioids were FDA-approved substances and that there were intervening causes (i.e., individuals not using the drugs as prescribed and doctors over-prescribing opioids) that contributed to the harm. However, in more recent years, mounting litigation lodged by governments may hold greater promise to succeed and reduce public health opioid-related harms, either through wins, settlements, or spillover effects. But let's be clear: litigation will not be a silver bullet to solving the crisis and shouldn't substitute for other public health-oriented policies and interventions. But lawsuits just might do some good here.  

Read more in our Perspective, entitled "Drug Companies' Liability for the Opioid Epidemic."

Minor Access to Prophylaxes in Massachusetts: STI Consent, the Mature Minor Rule, and the Definition of "Treatment"

By Jason Potter

The Massachusetts Joint Committee on Public Health is currently considering House and Senate bills to amend the Commonwealth’s emergency consent statute (Section 12F), which allows certain minors to self-consent to general medical care, and allows all minors to self-consent STI diagnosis and treatment. The bills would add the term “prevention” to the Commonwealth’s STI consent statute, thus allowing minors in Massachusetts to consent to STI diagnosis, treatment, and preventive care. Known as the “PrEP Bill,” S.1186 and H.3249 are sponsored by Senator Julian Cyr and Representative Jack Lewis, respectively. The senators are seeking to expand the language of the portion of Section 12F pertaining to STI-related care so minors may consent to HIV Pre-Exposure Prophylaxis (PrEP) and the human papillomavirus (HPV) vaccine. In my 2016 article PrEP and Our Youth: Implications in Law & Policy, I proposed this very change. On June 27, 2017, I testified before the Joint Committee in support of the PrEP Bill.

In its coverage of the hearing, the State House News Service declared that “[c]urrent law allows minors to consent to care without permission from a parent for treatment of sexually transmitted infections and HIV, but not for pre- or post-exposure treatments for HIV or for the human papillomavirus vaccine.” This suggestion that the PrEP Bill necessary to permit minors to self-consent to PrEP in the Commonwealth is not exactly true. If PrEP is considered a “treatment” under the Commonwealth’s common law “mature minor” rule and/or its STI consent statute, this would provide ample justification for furnishing PrEP to minors without parental consent. In this post, I argue that there is ample support for classifying PrEP, a prophylactic therapy, as “treatment” under either the common law rule or the Commonwealth’s STI consent statute. Therefore, while the PrEP Bill may provide clarification that preventive care is covered under the statute, it is not true that the bill is necessary to achieve that end.

In Massachusetts, notwithstanding statutory limitations, a minor with sufficient capacity to give informed consent may self-consent to medical care if the minor’s best interests are served by declining to seek parental consent. A court need not make the best interests determination; that assessment may be done by the provider. In Baird v. Attorney General, a 1977 case in the Massachusetts Supreme Judicial Court (SJC), the SJC concluded that “apart from statutory limitations . . . , where the best interests of a minor will be served by not notifying his or her parents of intended medical treatment and where the minor is capable of giving informed consent to that treatment, the mature minor rule applies in this Commonwealth.” The SJC then clearly stated that judicial intervention is not required, declaring that “[i]n such a case, . . .  judicial involvement is not required.” This common law rule, which is still good law in Massachusetts, is distinct from Section 12F. In fact, the Baird Court noted as much, stating that Section 12F “does not include all minors who might qualify in particular circumstances for application of a mature minor rule.” This language implies that the SJC intended the scope of the common law rule to be broader than the legislative rules.

Some community advocates in Massachusetts have indicated that the Baird Court’s mature minor rule is ineffective as applied to PrEP. According to advocates, the SJC’s specification of “treatment” (an undefined term) numerous times in the Baird holding leaves room for speculation as to whether PrEP is included. The argument goes that under a traditional definition of “treatment,” defined as the management and care of a patient to combat a disease, disorder, or condition, PrEP would not be included. PrEP is a prophylactic therapy prescribed to individuals who are not infected with the underlying disease, disorder, or condition and is, thus, distinct from treatment.

However, there are numerous reasons why prophylaxes are, indeed, treatments. First, the medication primarily used for PrEP is Truvada, an antiretroviral traditionally used as therapeutic HIV treatment but also applied for preventive purposes. The medication at the core of PrEP is principally a treatment drug. Second, excluding preventive therapies from the definition of treatment is logically inconsistent with the Baird Court’s intent to craft a broad rule. Such an implication would essentially mean that, in the ambit of STI-related care, the Commonwealth’s mature minor rule is functionally narrower than the STI-related language in Section 12F. Both specify treatment, but Section 12F also pertains to diagnosis (the common law rule does not), and further, the statute does not require the additional best interests consideration required by the Baird rule. In other words, a narrow reading of “treatment” in Baird that excludes prevention would mean that the common law rule is no more permissive but is, in fact, more limited than the statutory rule. This runs counter to the Baird Court’s suggestion that its mature minor rule should apply to circumstances outside the scope of the consent statute.

But more importantly, an interpretation of the term “treatment” that excludes PrEP ignores the fact that a minor may already self-consent under the common law rule (and Section 12F, for that matter) to HIV post-exposure prophylaxis (PEP). PEP is a combination of Truvada and another ARV administered for thirty days and is highly successful at preventing seroconversion if furnished within a 72-hour window of possible exposure to HIV. PEP is widely considered a “treatment.” After all, PEP treats the condition of exposure to HIV in those at significant risk of HIV infection. PrEP, too, is indicated for those “very high risk of coming in contact with HIV,” as these individuals sometimes have sex without a condom “when they have sex with a person who has HIV infection,” according to the CDC. Thus, the clinical profile of PrEP contemplates that the patient has already engaged in conduct that may have exposed him or her to HIV. Because both PEP and PrEP are considered appropriate for those who may have been exposed to HIV, the two therapies are so closely related that they are indistinguishable. The two therapies even share coding; recommended coding for both PrEP and PEP are “contact with and (suspected) exposure” to HIV (ICD-10, Z20.6). But the similarities do not end there. Both are termed prophylaxes. Both are “event driven” treatments. Both involve the same high-risk group. Both use the same drugs and have similar risks and benefits. (In fact, PEP may involve more risk to the minor because another ARV is added to the therapy.) Thus, since a minor may consent to PEP as treatment under the Baird mature minor rule, there is no reasonable argument that the law would exclude PrEP. In fact, in one of the only PrEP-related court decisions in the world, an Irish high court recently reached the same conclusion about the indistinguishability of PrEP and PEP, finding that any differences between the two “are differences without relevant distinctions.” [p. 31]. The indistinguishability of PrEP and PEP, in part, led the High Court of Justice to conclude that PrEP is a “treatment” under NHS England’s rules. [pp. 35-37].

Nearly all of these arguments that PrEP is a treatment apply with equal force to the STI consent statute, which is limited to “diagnosis and treatment.” But a consideration of whether PrEP is a treatment isn’t even necessary under the plain language the Section 12F. All that’s necessary is consideration of whether PrEP is related to diagnosis or treatment of HIV, for the STI consent statute states that a minor who believes himself to have or come into contact with an STI may “only consent to care which relates to the diagnosis or treatment of such disease.” There is no ambiguity here. PrEP is surely a type of care related to the treatment of HIV. PrEP is prescribed so the patient doesn’t need treatment in the first place. Not needing something is related to something. Since a prophylaxis prevents the need for treatment of infection, it relates to treatment of infection. Thus, I strongly aver that PrEP therapy (and the HPV vaccine, for that matter) may be prescribed under the existing STI consent statute pursuant to a plain reading of the statute.  

Therefore, the Commonwealth’s mature minor rule and its STI consent statute are each an independent basis for furnishing PrEP without parental consent. Providers in the Commonwealth should be especially confident furnish PrEP to self-consenting minors under the STI consent statute because it doesn’t even require taking the risk that a court may not consider PrEP a “treatment” if the issue was litigated. Again, all the STI consent statute requires is that the care is related to treatment of HIV.

Thus, while I support the PrEP Bill insofar as it eliminates any uncertainty in current law, I am not doing so because the PrEP Bill is necessary for minors to consent to PrEP in the Commonwealth. It is not.   

Could repealing net neutrality be bad for our health? [From Health Cents, philly.com]

The following post, from George Consortium member Robert I. Field, was originally published in Health Cents on philly.com.

By Robert I. Field

Repealing net neutrality could be bad for American health care.

The Federal Communications Commission plans to vote this week on a proposal to repeal Obama-era rules that require Internet Services Providers, companies that connect your computer to the Internet like Comcast and Verizon, to treat all websites equally. The rules prohibit ISPs from speeding up or slowing down traffic to a site for financial or other reasons.

Net neutrality makes all websites equally accessible. It puts start-up sites on the same footing as the sites of large corporate players like Google and Facebook. Without those rules, ISPs could reward sites that pay fees for faster access and punish those that do not.

The effects of repealing the rules could reach far and wide. They could even affect the future of health care.

The Internet is key to the spread of telemedicine, the next frontier in medical practice. This technology gives patients in rural areas and those with limited mobility the same access to top physicians as those who live in big cities and have greater mobility. It can bring expert consultations into patients’ homes and allow them to share information with physicians who are thousands of miles away. In the not-too-distant future, telemedicine may help everyone to see top specialists for examinations and even treatments from the comfort of home.

But telemedicine consultations, which travel over the Internet, require the transmission of large amounts of data. They rely on data-hogging video, and the video must be encrypted to comply with federal privacy rules, adding additional data demands. Without net neutrality rules, ISPs might balk at providing sufficient bandwidth.

The major ISPs promise that they will continue to abide by the principles of net neutrality, even without a legal mandate. But telemedicine consultations may have to connect to the networks of smaller ISPs in rural areas that may not follow suit. And what guarantees are there that the larger ISPs will keep their promises indefinitely in the face of financial temptation? Telemedicine uses bandwidth that could be redirected to corporate sites willing to pay top dollar. Medical practices, especially smaller ones, may have difficulty affording the cost.

And as medicine advances, new web-based technologies are certain to arise and face similar impediments. Wider use of electronic medical records is especially at risk.

The Internet has become essential for many aspects of our lives. If net neutrality goes away and the open Internet disappears, it is not just access to social media and movie downloads that could become more difficult. The future of medical innovation could be diminished as well.

[Original post from Health Cents on philly.com can be found here.]

"Benefits, Limitations, and Value of Abuse-Deterrent Opioids" in JAMA Internal Medicine

Two members of our team - Dr. Gregory Curfman and Professor Leo Beletsky - and friend of PHLW Ameet Sarpatwari have an important new piece out in JAMA Internal Medicine entitled "Benefits, Limitations, and Value of Abuse Deterrent Opioids."  "Abuse deterrent opioids" are formulations of the drugs meant to be tamper-resistant, "intended to make manipulation more difficult or to make abuse of the manipulated product less attractive or less rewarding." Looking at the Institute for Clinical and Economic Review report on Abuse-Deterrent Formulations of Opioids: Effectiveness and Value and adding independent analysis, the authors found that the selective use of abuse deterrent opioids may mitigate opioid abuse and diversion. However, the use may also promote switching to more dangerous opioids (like heroin). Finally, they found no evidence that abuse deterrent opioid use reduces overdose deaths. 

Read the entire article here.

Why is Congress not prioritizing health care for children and other vulnerable populations?

By Jennifer Lea Huer

Back in September of this year, Congress was faced with the decision of whether or not to renew funding for both the Children’s Health Insurance Program (CHIP) and the Community Health Center Fund. Both sources of funding expired on October 1, 2017. As of the date of this post, 68 days have passed since Congress failed to renew funding for these crucial programs. Much has been written about the imminent need to reauthorize CHIP funding; states are already warning their residents that funding is running low and decisions about cutting coverage may soon follow. In addition to the estimated 9 million children in danger of losing coverage if CHIP funding is not renewed, recent studies estimate that millions more people could lose access to care if Congress does not take concrete steps to reauthorize funding for community health centers.

The federal government formalized its commitment to community health centers (CHCs) back in 1965, when it established the Health Center Program – a program that champions the development and capacity of CHCs, especially in the provision of care for millions of our country’s most vulnerable patients. The Patient Protection and Affordable Care Act (ACA) reiterated the US commitment to CHC growth and funding by establishing the Community Health Center Fund. The ACA authorized five years of funding, a total of about $7 billion, for CHCs. This funding meant that every state in the United States, including the District of Columbia, could have at least one CHC.  Federal funding also led to implementation of primary care programs, as well as behavioral health programs, and specific programs focused on special populations (e.g., veterans, children, chronically ill, homeless). Upon its expiration in 2015, Congress extended community health center funding for an additional two years, which, as mentioned, expired on October 1st.

Congress’ inaction is of the utmost concern, because community health centers are essential components of the American health care system, providing primary care services to more than 27 million people each year. One in 12 patients are served by a federally-funded CHC. Twenty-five percent of rural Americans receive their primary care from a CHC. An overwhelming percentage of CHC patients represent racial and ethnic minority groups. As other settings within the health care system continue to grow and cost more money, CHCs find themselves struggling to provide care to increasingly larger volume of patients, particularly for patients who would otherwise not have access to appropriate and cost-effective primary and ambulatory care services.

CHCs are known to provide high quality care and have a low per patient cost, but because the majority of their patients are under- or uninsured, CHCs heavily rely on federal support to maintain financial stability. Federal support for CHCs comes in the form of grants – which account for 70% of CHC funding. And end to the health center program means that CHCs will lose 70% of their funding, which will result in what experts have termed a “funding cliff.” This situation is especially dire for states that chose not to expand Medicaid; CHCs have even higher numbers of uninsured patients in these states (when CHCs cannot rely on Medicaid payments for otherwise reimbursable services, they must utilize more of their federal grant dollars to provide direct care, rather than using that grant funding to expand capacity for care delivery and specialized programs).  Experts are also forecasting that beyond stress to the health care system, this significant loss of funding will have detrimental effects in other sectors of our economy, including employment and state tax revenue.

Interestingly, both the House and the Senate have introduced bills that would extend funding for CHCs. But while both chambers have referred the Community Health Investment, Modernization, and Excellence Act of 2017 to sub-committees for review, the bills have stalled, with no further action occurring since September.

Here in Massachusetts, CHCs are trying not to panic, but many are worried that they will need to cut staff, clinic hours, and in the worst cases, shut down their facilities. The CHC funding cliff would result in Massachusetts CHCs losing $196 million in funding, which would impact hiring of new staff, continuation of much needed expansions (facility and programmatic), and, most importantly, it would mean that more than 141,000 residents could go without health care.

As the Trump Administration continues to aggressively degrade the integrity of the ACA and health care in the United States, CHCs will find themselves pressured to rise to the challenge of filling gaps in care delivery and cost containment. The CHIME Act indicates bipartisan recognition and support for solving the impending funding crisis, but Congress has not stopped internal squabbling long enough to focus on acting in the best interest of its constituents. It’s time members of Congress prioritize serving those who need them most and move to immediately reauthorize funding for the Community Health Center Fund.